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 * Note: Please use your sandbox to submit assignment # 3 by pasting it below. When uploading your improvements to the article talk page please share your exact proposed edit (not the full assignment 3).


 * Talk Page Template: CARL Medical Editing Initiative/Fall 2019/Talk Page Template

 Delirium 

Assignment #2
Soiza, R. L., & Myint, P. K. (2019). The Scottish Intercollegiate Guidelines Network (SIGN) 157: Guidelines on Risk Reduction and Management of Delirium. Medicina (Kaunas, Lithuania), 55(8), 491. doi:10.3390/medicina55080491

How did I search for the source?

I conducted the following search strategy in PubMed:

("delirium"[MeSH Terms] OR "delirium"[All Fields]) AND ("therapy"[Subheading] OR "therapy"[All Fields] OR "treatment"[All Fields] OR "therapeutics"[MeSH Terms] OR "therapeutics"[All Fields]) AND ("guideline"[Publication Type] OR "guidelines as topic"[MeSH Terms] OR "guideline"[All Fields]) AND ("2014/11/07"[PDat] : "2019/11/05"[PDat])

Which sources were considered?

Soiza, R. L., & Myint, P. K. (2019). The Scottish Intercollegiate Guidelines Network (SIGN) 157: Guidelines on Risk Reduction and Management of Delirium. Medicina (Kaunas, Lithuania), 55(8), 491. doi:10.3390/medicina55080491

Guthrie, P. F. (2018). Evidence-Based Practice Guideline: Delirium. Journal of gerontological nursing, 44(2), 14-44.

Why was the source chosen?

The ‘SIGN 157’ source was chosen as it is one of the most recent published practice guidelines on delirium. As well, it offers more information on the role of medication in treating delirium than other sources found. Making reference to various comprehensive/recent articles, it is considered an evidence-based resource on delirium management.

List at least three reasons why the source that was selected meets Wikipedia’s reliable medical sources (MEDRS) criteria?


 * SIGN 157 is a secondary source, which is a requirement of the MEDRS criteria
 * SIGN 157 is a practice guideline shared by a major medical authority (Scottish Intercollegiate Guidelines Network), which is one of the sources outlined by the MEDRS criteria
 * Given that this guideline was published in 2019, it offers recent and up-to-date advice on delirium management, which is in line with the MEDRS criteria of using up-to-date evidence (more recent than five years)

How do I plan to use the source for improving the article?

Currently, the Wikipedia article is unclear on whether or not medications such as antipsychotics are used in treating delirium. Our tutor found this concerning as patients may be misled into believing they need a certain medication to manage their symptoms. I plan to use this source to update recommendations regarding medications for delirium in the Wikipedia article.

Assignment #3
Proposed Changes

Evidence for the effectiveness of medications (including antipsychotics and benzodiazepines) in treating delirium is inconclusive. The treatment for delirium with medications depends on its cause.

Low-dose haloperidol when used short term (one week or less) is the most studied and standard drug for delirium. Evidence for efficacy of atypical antipsychotics (i.e. risperidone, olanzapine, ziprasidone, and quetiapine) is emerging, with the benefit for fewer side effects. Antipsychotics however are not supported for the treatment or prevention of delirium among those who are in hospital. Use antipsychotic drugs with caution or not at all for people with conditions such as Parkinson's disease or dementia with Lewy bodies.

Benzodiazepines themselves can trigger or worsen delirium, and there is no reliable evidence for use in non-alcohol-related delirium. If the delirium involves alcohol withdrawal, benzodiazepine withdrawal, or contraindications to antipsychotics (e.g. in Parkinson's disease or neuroleptic malignant syndrome), then benzodiazepines are recommended. Similarly, people with dementia with Lewy bodies may have significant side effects to antipsychotics, and should either be treated with a none or small doses of benzodiazepines.

The antidepressant trazodone is occasionally used in the treatment of delirium, but it carries a risk of over-sedation, and its use has not been well studied.

Rationale for Proposed Change


 * 1) Proposed Change #1: The literature surrounding the efficacy of antipsychotic use is contradictory and no clear conclusions can be made from previous research. It is thus important that the Wikipedia page reflect this uncertainty surrounding antipsychotics. It would be incorrect to say that delirium treatment depends on its cause as there is a lack of conclusive literature supporting the efficacy of medications  for delirium, regardless of cause. As well, the sentence stating that antipsychotics are not supported for delirium treatment among people in hospital is misleading as it suggests that patients not in hospital could be recommended antipsychotics. That is why we propose including a sentence that states what we know about antipsychotics in delirium, which is that its results are inconclusive.
 * 2) Controversy or varied opinion: There was uncertainty whether the proposed change would be clear enough for laypeople to understand that antipsychotics are not necessarily the recommended first line of therapy for delirium. After some deliberation, it was decided that the wording of this sentence is the most accurate message we wish to send laypeople, as we do not conclusively know whether antipsychotics effectively treat delirium or not.
 * 3) Proposed Change #2: The SIGN guidelines do not show conclusive evidence for benzodiazepines in treatment of delirium, and thus they should not be recommended for people with dementia with Lewy bodies. Rather, the NICE guidelines stress caution when using antipsychotics for people with dementia with Lewy bodies, which is what we would like to include in the Delirium page.
 * 4) Controversy or varied opinion: After seeing that the SIGN guidelines did not have conclusive evidence for the efficacy of benzodiazepines in treating delirium, it felt reasonable to remove the corresponding sentence from the page. However, our faculty advisor felt it was important to replace this sentence with information relevant to the patient population that also has dementia with Lewy bodies. In order to do this, we consulted the NICE guidelines for their treatment recommendations for this subset of patients. As well, it was mentioned that Lewy bodies may not be easily understandable for laypeople. This will be addressed by linking the words “Lewy bodies” to its corresponding Wikipedia page for readers to reference to.

Critique of Source

A potential bias of concern with regards to the SIGN guidelines is that the writers of the guideline are employees of SIGN, which could create a conflict of interest. However, this concern is mitigated knowing that the process used to create the SIGN guidelines has been accredited by NICE. As well, we made sure to consult the NICE guidelines to confirm information and reduce potential for bias.

Sources

Soiza, R. L., & Myint, P. K. (2019). The Scottish Intercollegiate Guidelines Network (SIGN) 157: Guidelines on Risk Reduction and Management of Delirium. Medicina (Kaunas, Lithuania), 55(8), 491. doi:10.3390/medicina55080491

National Institute for Health and Care Excellence. Delirium: NICE quality standard 63. UK: National Institute for Health and Care Excellence, 2014. guidance.nice.org.uk/qs63